Learning objectives for thoracic surgery: developing a national standard for undergraduate medical education.

BACKGROUND: The Continuing Professional Development (CPD) (Education) Committee of the Canadian Association of Thoracic Surgeons (CATS) has established a goal of describing the essential knowledge of thoracic surgery. We aimed to develop a national standardized set of undergraduate learning objectives for thoracic surgery. METHODS: We obtained these learning objectives from 4 medical schools in Canada. These 4 institutions were selected to provide a broad geographical representation of medical schools of varying sizes and of both official languages. The resulting list of learning objectives underwent critical review by the CPD (Education) Committee, made up of 5 Canadian community and academic thoracic surgeons, 1 thoracic surgery fellow and 2 general surgery residents. A national survey was developed and circulated to all CATS members (n = 209). Respondents were asked to indicate on a 5-point Likert scale whether each objective should be a priority for all medical students. RESULTS: Among 209 CATS members, 56 responded (response rate 27%). The mean length of experience in clinical practice among survey respondents was 10.6 (standard deviation 10.0) years. Respondents most commonly reported teaching or supervising medical students monthly (37.0%), followed by daily (29.6%). Eight of the 10 proposed objectives received a mean Likert score of 4/5 or higher and were selected for inclusion in the final list. A finalized list of 8 learning objectives was created, following a final review from the CATS Executive Committee. CONCLUSION: We developed a standardized set of learning objectives for medical students that was reflective of the core concepts within thoracic surgery.

Evolution of Process and Outcome Measures during an Enhanced Recovery after Thoracic Surgery Program.

BACKGROUND: A time course analysis was undertaken to evaluate how perioperative process-of-care and outcome measures evolved after implementation of an enhanced recovery after thoracic surgery (ERATS) program. METHODS: Outcome and process-of-care measures were compared between patients undergoing major elective thoracic surgery during a 9-month pre-ERATS implementation period to those at 1-3, 4-6, and 7-9 months post-ERATS implementation. Outcome measures included length of stay, the 30-day readmission rate, 30-day emergency department visits, and minor and major adverse events. Process measures included first time to activity, out-of-bed, ambulation, fluid diet, diet as tolerated, as well as removal of the first and last chest tube, epidural, patient-controlled analgesia, and Foley and intravenous catheters. RESULTS: In total, 704 patients (352 pre-ERATS, 352 post-ERATS) were included. Mobilization-related process measures, including time to first activity (16.5 vs. 6.8 hours, p<0.001), out-of-bed (17.6 vs. 8.9 hours, p<0.001), and ambulation (32.4 vs. 25.4 hours, p=0.04) saw statistically significant improvements by 1-3 months post-ERATS implementation compared to pre-ERATS. Time to Foley removal improved by 4-6 months post-ERATS (19.5 vs. 18.2 hours, p=0.003). Outcome measures, including the 30-day readmission rate and emergency department visits, steadily decreased post-ERATS. By 7-9 months post-ERATS, both minor (18.2% vs. 7.9%, p=0.009) and major (13.6% vs. 4.4%, p=0.007) adverse events demonstrated statistically significant improvements. Length of stay trended towards improvement from 6.2 days pre-ERATS to 4.8 days by 7-9 months post-ERATS (p=0.06). CONCLUSION: The adoption of ERATS led to improvements in multiple process-of-care measures, which may collectively and gradually achieve optimization of clinical outcomes.

The longitudinal impact of division-wide implementation of an enhanced recovery after thoracic surgery programme.

OBJECTIVES: Data regarding enhanced recovery after thoracic surgery (ERATS) are sparse and inconsistent. This study aims to evaluate the effects of implementing an enhanced ERATS programme on postoperative outcomes, patient experience and quality of life (QOL). METHODS: We conducted a prospective, longitudinal study evaluating 9 months before (pre-ERATS) and 9 months after (post-ERATS) a 3-month implementation of an ERATS programme in a single academic tertiary care centre. All patients undergoing major thoracic surgeries were included. The primary outcomes included length of stay (LOS), adverse events (AEs), 6-min walk test scores at 4 weeks, 30-day emergency room visits (without admission) and 30-day readmissions. The process-of-care outcomes included time to 'out-of-bed', independent ambulation, successful fluid intake, last chest tube removal and removal of urinary catheter. Perioperative anaesthesia-related outcomes were examined as well as patient experience and QOL scores. RESULTS: The pre-ERATS group (n = 352 patients) and post-ERATS group (n = 352) demonstrated no differences in demographics. Post-ERATS patients had improved LOS (4.7 vs 6.2 days, P < 0.02), 6-min walk test scores (402 vs 371 m, P < 0.05) and 30-day emergency room visits (13.7% vs 21.6%, P = 0.03) with no differences in AEs and 30-day readmissions. Patients experienced shorter mean time to 'out-of-bed', independent ambulation, successful fluid intake, last chest tube removal and urinary catheter removal. There were no differences in postoperative analgesia administration, patient satisfaction and QOL scores. CONCLUSIONS: ERATS implementation was associated with improved LOS, expedited feeding, ambulation and chest tube removal, without increasing AEs or readmissions, while maintaining a high level of patient satisfaction and QOL.

Patterns of Practice in Mediastinal Lymph Node Staging for Non-Small Cell Lung Cancer in Canada.

BACKGROUND: Assessment of mediastinal lymph nodes is integral in staging patients with non-small cell lung cancer (NSCLC). This study delineated the lymph node staging practices of Canadian thoracic surgeons in patients with potentially resectable NSCLC. METHODS: A questionnaire was distributed to Canadian Association of Thoracic Surgeons members (n = 86). Items addressed the use of imaging, thresholds/methods for preoperative invasive staging, and intraoperative node staging. Comparison was made against Canadian, American, and European guidelines. RESULTS: Forty-seven surgeons (55%) responded. Although most stated they derived practices from published guidelines, a significant proportion did not reflect those recommendations. Most respondents ordered a positron emission tomography scan for every patient (87.2%), and the same proportion (87.2%) performed invasive staging selectively, with a wide range of indications. The most common thresholds were suspicious nodes on imaging (80.5%), tumor within the central third of the lung (67.5%), and tumor exceeding 3 cm (34.2%). Endobronchial ultrasound, alone or with endoscopic ultrasound, was selected as the initial staging procedure of choice by 47.9%, and 43.5% selected mediastinoscopy first. Of surgeons selecting mediastinoscopy, 61.9% reported some barriers to performing endobronchial ultrasound. There was variability, between surgeons and between lobes, in which nodes respondents harvested intraoperatively for given lobectomies. A sizeable minority (13%) did not routinely harvest lymph nodes intraoperatively. CONCLUSIONS: Determining the appropriate treatment and prognosis of NSCLC patients relies on proper staging. Significant variability exists in node staging practices in Canada as well as divergence from guidelines. This may result in understaging or overstaging patients and inappropriate care.

Dual-energy computed tomography: a promising novel preoperative localization study for treatment of primary hyperparathyroidism.

BACKGROUND: The objective of this study was to evaluate dual-energy computed tomography (DE-CT) for preoperative parathyroid tumor (PT) localization in individuals undergoing parathyroidectomy for treatment of primary hyperparathyroidism (PHP). METHODS: DE-CT was evaluated by retrospective review of the clinical and biochemical characteristics, imaging, operative findings, and outcomes for PHP cases undergoing an initial operation at a single center. RESULTS: The accuracy of each preoperative imaging test, based on operative findings and pathological confirmation of removal of a PT from the localized site was: 58% for ultrasound, 75% Tc-99m sestamibi noncontrast single photon emission noncontrast CT, and 75% for DE-CT. DE-CT was able to correctly localize a PT in a 3rd of cases that were nonlocalized. All study patients had normalization of serum calcium and parathyroid hormone levels postoperatively. CONCLUSIONS: DE-CT shows promise for the preoperative PT localization, especially in nonlocalized PHP cases, and warrants further investigation.

Axillary reverse mapping in breast cancer: a Canadian experience.

BACKGROUND: The aim of this study was to evaluate the axillary reverse lymphatic mapping (ARM) procedure for reducing the risk of arm lymphedema after breast cancer surgery. METHODS: The ARM procedure was carried out with a subareolar injection of technetium-99 sulfur colloid the morning of surgery, and a patent blue dye injection into the upper inner arm after anesthesia. RESULTS: Fifty-two women made up our study population. Thirty-seven patients underwent sentinel lymph node biopsy (SLNB) and 15 patients underwent an axillary lymph node dissection (ALND) for known nodal metastasis. The sentinel lymph node was identified in 36 of the 37 cases who underwent SLNB alone and in 12 of 15 patients who underwent on ALND. In 13 patients, both blue and radioactive lymph nodes or lymphatics were clearly identified (25%) and 5 patients had a clear crossover with nodes being both blue and hot. Only a single patient with crossover lymphatics had metastases present in their sentinel node. CONCLUSION: The ARM technique did not prevent identification of the SLN and we identified much greater crossover than reported. We had a single patient, who underwent a sentinel node biopsy, with mild arm lymphedema (1.9%) after 2 years of follow up.

Axillary reverse lymphatic mapping in breast cancer surgery: a comprehensive review.

Axillary reverse lymphatic mapping (ARM) is a surgical technique that was first described in 2007 as a method for preserving the lymphatic drainage of the arm during sentinel lymph node biopsy (SLNB) or axillary lymph node dissection (ALND) for breast cancer. We found that the ARM technique had several limitations that include a poor success rate for identification of arm lymph nodes (ARM nodes) and lymphatics. The occurrence of common lymphatic drainage pathways of the arm and the breast in a subset of patients also raises concerns regarding its oncological soundness. Furthermore, the effectiveness of the ARM procedure in reducing lymphedema risk in breast cancer patients that undergo a variety of treatments, has yet to be clearly defined.

Small-airway obstruction and emphysema in chronic obstructive pulmonary disease.

BACKGROUND: The major sites of obstruction in chronic obstructive pulmonary disease (COPD) are small airways (<2 mm in diameter). We wanted to determine whether there was a relationship between small-airway obstruction and emphysematous destruction in COPD. METHODS: We used multidetector computed tomography (CT) to compare the number of airways measuring 2.0 to 2.5 mm in 78 patients who had various stages of COPD, as judged by scoring on the Global Initiative for Chronic Obstructive Lung Disease (GOLD) scale, in isolated lungs removed from patients with COPD who underwent lung transplantation, and in donor (control) lungs. MicroCT was used to measure the extent of emphysema (mean linear intercept), the number of terminal bronchioles per milliliter of lung volume, and the minimum diameters and cross-sectional areas of terminal bronchioles. RESULTS: On multidetector CT, in samples from patients with COPD, as compared with control samples, the number of airways measuring 2.0 to 2.5 mm in diameter was reduced in patients with GOLD stage 1 disease (P=0.001), GOLD stage 2 disease (P=0.02), and GOLD stage 3 or 4 disease (P<0.001). MicroCT of isolated samples of lungs removed from patients with GOLD stage 4 disease showed a reduction of 81 to 99.7% in the total cross-sectional area of terminal bronchioles and a reduction of 72 to 89% in the number of terminal bronchioles (P<0.001). A comparison of the number of terminal bronchioles and dimensions at different levels of emphysematous destruction (i.e., an increasing value for the mean linear intercept) showed that the narrowing and loss of terminal bronchioles preceded emphysematous destruction in COPD (P<0.001). CONCLUSIONS: These results show that narrowing and disappearance of small conducting airways before the onset of emphysematous destruction can explain the increased peripheral airway resistance reported in COPD. (Funded by the National Heart, Lung, and Blood Institute and others.).

The disruption of the epithelial mesenchymal trophic unit in COPD.

Progression of COPD is associated with a measurable increase in small airway wall thickness resulting from a repair and remodeling process that involves fibroblasts of the epithelial mesenchymal trophic unit (EMTU). The present study was designed to examine the organization of fibroblasts within the lamina propria of small airways with respect to their contacts with the epithelium and with each other in persons with COPD. Transmission electron microcopy (TEM) and three-dimensional (3D) reconstructions of serial TEM sections were used to estimate the frequency and determine the nature of the contacts between the epithelium and fibroblasts within the EMTU in small airways from 5 controls (smokers with normal lung function), from 6 persons with mild (GOLD-1) and 5 with moderate (GOLD-2) COPD. In airways from control lungs fibroblasts make frequent contact with cytoplasmic extensions of epithelial cells through apertures in the epithelial basal lamina, but the frequency of these fibroblast-epithelial contacts is reduced in both mild and moderate COPD compared to controls (p < 0.01). The 3D reconstructions showed that the cytoplasmic extensions of lamina propria fibroblasts form a reticulum with fibroblast-fibroblast contacts in an airway from a control subject but this reticulum may be reorganized in airways of COPD patients. Development of COPD is associated with significant disruption of the EMTU due to a reduction of contacts between fibroblasts and the epithelium.